A History of the Scottish
People
Health in Scotland, 1840 - 1940 by W W Knox

Reprinted here
for Educational Purposes Only

1. INTRODUCTION

Historically Scotland has had a poor record in
matters of health. Even today, in spite of important advances in
medical knowledge and the provision of health care, Scotland has one
of the worst incidences of lung cancer and coronary heart disease in
the world. However, to concentrate solely on these admittedly alarming
statistics would be to obscure the tremendous progress medicine has
made in this country in combating the diseases which beset Scottish
people in the 19th century. Cholera, typhus and smallpox were major
killers in the 19th century and were the result of environmental
pollution, poverty and bad housing. However, advances in medicine, and
improvements in the environment and diets of people has led to their
eradication.

The major killer diseases today are more the
result of post-World War Two affluence than poverty. Obesity,
alcoholism and smoking have greatly increased due to higher standards
of living and they have had an adverse affect on health standards. As
each disease has been conquered a new one seems to have emerged to
take its place and so the fight against disease continues. But what
was the level of ill-health In the 19th and 20th centuries and how did
the authorities in Scotland seek to deal with it?

2. ILL-HEALTH 1840-1900

2.1 AN OVERVIEW

The rapid growth in Scotland's urban population
in the 19th century brought with it unprecedented social problems, of
which ill-health was one. However, although ill-health was recognised
as a major social problem, our knowledge of death rates and the causes
of death in the first half of the 19th century is patchy. It was not
until 1855 that the civil registration of births and deaths was
introduced. Even after this date many deaths went uncertified, or the
causes were wrongly entered on the death certificate. Still-born
babies went unregistered and had no burial ceremony. In places with
few doctors the case of death was badly recorded, with 24% of deaths
in Glasgow uncertified in 1871. By 1893 this had been reduced to 3.6,
but in Inverness 42% of deaths were still uncertified.

In spite of the poor statistical information
available to historians it vould appear that although disease was a
feature of rural life, it was more of a problem in cities. Between
1835 and 1845 the average death rate in 331 rural parishes, with a
total population of 751,016 was 20. per 1000. The average death rate
in the 14 principal towns of Scotland, with almost exactly the same
population, was 26.7 per 1000. The lower death rate for the rural
parishes was largely due to the fact that people living in the country
were spread out over a large area, which meant that in times of
epidemics they had a natural system of quarantine. The generally
healthier environment in the countryside also helped build up
resistance to disease. However, at the end of the 19th century
returning migrant workers from the Lowland cities brought tuberculosis
with them and the damp condition of the housing saw it spread like
wildfire through the Highlands.

In the cities conditions were much less healthy
and overcrowding was a marked feature of life for the urban poor.
Twelve to sixteen people to a room was not uncommon in the poorer
parts of Edinburgh and Glasgow. Not surprisingly, the highest death
rates were in the most densely populated areas of the cities. A study
of Edinburgh in the early 1860s showed that the highest death rates
were in the Tron, Canongate and Grassmarket areas with densities of
353, 238 and 220 persons per acre; and the lowest were in Morningside,
Newington, Broughton and the Grange with densities of 8, 40, 49 and 16
persons per acre. The most common causes of death in 19th century
Scotland were, in order of importance:-

1. Diseases of the brain and nervous system2. Diseases of the respiratory system3. Diseases of the heart4. Diseases of the digestive organs5. Epidemic and contagious diseases

The diseases causing the most deaths were
tuberculosis, typhus, scarletina, whooping cough, smallpox and
measles. In the 1860s two-fifths of all deaths in Glasgow were due to
respiratory diseases and tuberculosis,

2.2 CHILD MORTALITY

The age group most vulnerable to death by illness
was the very young. Deaths of children under ten accounted for more
than half the deaths in Glasgow in the early 19th century, and even as
late as 1861 some 429/6 of all deaths in the city were in this age
group. In Scotland as a whole, the Registrar Generals first annual
report in 1861 found that the highest proportion of deaths occurred in
the age group under five years. Children born in one-room homes
(single ends') were most vulnerable. Of all children in Glasgow who
died before the age of five 32' were born or living in single ends,
while only 2% were in five roomed homes. Appalling as these figures
for infant deaths were Scotland fared better than England in this
respect.

The infant mortality rate for England and Wales
in the early 1850s was 150 deaths per 1000 live births; in Scotland it
was 120 per 1000. In the 1890s there was a deterioration in the
Scottish figures as infant mortality rose to 129 per 1000 live births.
By 1913 the Scottish rate was only slightly better than the English.
But if we look at the poorest areas of, say, Glasgow then the Scottish
figures are as bad as anywhere else. As late as 1898 the infant
mortality rate in Glasgow Gorbals was 200 per 1000 live births. The
reason for this was the increased concentration of the population in
urban areas and their poverty. Scotland really only fared better than
England in the first half of the 19th century because a higher number
of its people were living in the countryside.

2.3 SOME DEADLY DISEASES

The death rate among children dramatised the link
between ill-health and disease and social conditions. As such this
proved hard to remedy, but some success was achieved in dealing with
the major killer diseases. The impetus to combat disease came from the
fight against cholera. As one historian put it "The greatest factor in
ensuring reform and legislation was the appearance of cholera'. What
made cholera induce social panic was its deadliness; 50% of those who
contracted the disease in 1 832 died. Another reason was the fact that
it struck at all social classes. Other diseases such as tuberculosis
and typhus could be dismissed by the middle classes as the result of
filth and squalor and could be interpreted as a punishment of God.
Cholera could not as it affected the virtuous and immoral alike,
However, finding a cure for killer diseases proved difficult due to
the disagreements among doctors as to the causes of disease.

One school of thought, known as the miasmatics
and led by the great English social reformer, Edwin Chadwick, was
convinced that the cause of disease was due to toxic odours in the
atmosphere. These were the result of dirt and poor sanitation. The
solution was to clean up the streets and provide an efficient means of
disposing of human waste. The other school was known as the
contagionists. They believed that disease was spread by touch and
originated in contaminated water supplies. Poverty and bad housing
facilitated its spread as the resistance of the less fortunate was
low, The latter view dominated the thinking of medical men in
Scotland. They did not oppose sanitary reform but saw the provision of
pure drinking water as a first priority. They also called for a more
generous Poor Law.

A cholera epidemic in Glasgow in 1847-184-8 saw
the first step taken to improve public health standards, An Act of
Parliament in 1855 allowed Glasgow to draw water from Loch Katrine at
a cost of £1 ,5rn, which gave it the best public supply of water in
the UK. As a result, when cholera struck again in 1865-6 only 53
people died in Glasgow, Dundee and Edinburgh quickly followed suit and
provided improved water supplies. However, other diseases took longer
to conquer. That tuberculosis was an infectious disease carried by a
bacillus was not realised until 1884, and it took much longer to
eradicate In the period 18611870 TB killed 361 in every 100,000; in
1901-1910 it was still high at 209. It took until the 1940s and the
discovery of penicillin for respiratory diseases like TB to be brought
under control, Until that time they remained the main killer.

Epidemics and poor health were not simply the
products of bad housing and defective drinking supplies. Part of the
problem lay with conditions in the workplace and also food and drink
adulteration. A study of Tranent, near Edinburgh, in the 1840s found
that mining, because of the dirt and dust, was an unhealthy trade Out
of 35 colliers' families, the average age at death for the male
head-of-household was 34, while the average age at death for male
factory workers was over 51.

Ignorance of the basic principles of hygiene was
also an important factor in the generation and spread of disease. It
was not a common practice to boil water in the 19th century, nor was
bathing popular. Dirty water and unclean bodies were major factors in
the spread of diseases such as cholera and typhoid. Milk and other
dairy products were a common breeding ground for scarlet fever and
diphtheria. Dairies and shopkeepers diluted milk with (infected) water
to yield greater profits. Beer was even adulterated with narcotic
substances such as strychnine to counter the effect of over dilution
with water of the original. The effect was slow poisoning. Of course,
alcohol consumption, mainly of whisky, induced all manner of health
problems, and Scotland's reputation for drunkenness was legend. The
problem of food and drink pollution was addressed with a law in 1860
banning the adulteration of milk. At about the same time alcohol
consumption started to reduce. The consumption of whisky which stood
at 1.65 gallons a year per head of the population in 1861 fell to just
0.40 gallons a year by 1931.

2.4 SOME IMPROVEMENTS

Much of the reduction in disease and other health
problems was due to rising standards of living and changes in
lifestyle. However, it was also due to improved public health
administration and the provision of health care. Because of the
Scottish medical profession's opposition to the miasmatics, Scotland
was not included in the Public Health Act of 1848, but in spite of
this the administration of health standards was gradually improved.
Until the late 19th century most health care was provided by parishes
and the standards varied according to the wealth of the parish. The
shortfalls in local authority care were supposed to be made up by
charitable medical services. The whole system was haphazard and any
improvements were down to local initiatives. Large burghs used the
device of Police Acts to appoint medical officers of health, as
happened in Edinburgh and Glasgow in the early 1860s, However, it took
until 1889 with the passing of the Local Government Act for public
health affairs to be put on a more organised footing.

The legislation required local authorities to
appoint a medical officer of health, whose activities, and those of
sanitary inspectors, were subject to the control and supervision of
the Local Government Board. The appointment of medical officers of
health meant that a whole host of environmental issues, such as air
and water pollution, could be addressed and remedied. Encouragement
was also given to the building of drainage and sewage systems in
larger villages and small towns. Inadequacies in providing sanitary
appliances in housing such as sinks and WCs were also dealt with.
Despite the clear progress made in these areas by 1900 a number of
outstanding issues still had to be addressed. Ash-pits and middens
were still being used for human waste, and the removal of dirt and
refuse was only being carried out once a fortnight, or less, in the
large burghs, Moreover, the supply of water to homes was obstructed by
ratepayers on grounds of cost. This led to the storing of water in the
home, a practice which led to contamination.

2.5 MEDICAL FACILITIES

Although progress was clearly evident in
Improving the environment and the water and sanitation systems, the
slow pace of reform was small comfort to those stricken by disease and
ill-health, What was available in terms of health care for the sick
and diseased in the 19th century? Unless one was a pauper, all health
care at this time had to be paid for privately. There was no
equivalent of the National Health Service. If a person was ill there
were three types of care available: treatment in a voluntary hospital;
treatment in a poor law hospital; and treatment at home by a doctor.
The voluntary or teaching hospitals were superior medical institutions
with first class facilities and staff. They were supported by private
donations, endowments and subscriptions. To receive treatment a
patient had to he provided with a 'line' signed by a subscriber, All
patients had to leave the hospital within 40 days, and funeral
expenses were to be guaranteed by the subscriber, Certain categories
of patient were not admitted - the poor, as poorhouses dealt with
them, apprentices and servants, who were to be looked after in their
masters' houses. There were also some illnesses considered unsuitable
for entry, including those associated with pregnant women, and
incurable diseases such as smallpox.

From 1345 the very poor and those suffering from
incurable diseases were treated in Poor Law hospitals. As treatment
was financed out of the rates the managers of the hospitals were under
pressure to keep expenditure down, something which led to economies in
the provision of medical facilities. From the 1850sto 1870s operations
for the removal of tumours were performed in the patient's own bed or
on a table in the ward as there were no funds for separate operating
rooms. At the busiest times of the year patients, usually children,
had to share beds. Baths, sinks and WCs were in short supply. In the
Barony parish of Glasgow in 1883 the occupants of wards 141 (skin
diseases) and 142 (venereal disease) shared the same WC and bath. It
was not until the end of the 19th century that the problems in Poor
Law hospitals were addressed, In Glasgow there was a hospital building
programme initiated which did much to relieve the pressure of
overcrowding. The programme allowed for the separation of the
hospitals from the poor houses, and those with minor illnesses from
those with chronic ones. But it remained a fact that only those
applying for poor relief could gain admittance to the system, the rest
had to rely on the expensive voluntary hospitals or charity.

Those on poor relief could also receive visits
from the parish doctor and call at his surgery free of charge. This
outdoor medical service was, however, stretched to the limit. The
doctor was only employed on a part-time basis and the number of
patients in his care was quite phenomenal. In the city parish of
Glasgovv in 1875 one doctor was employed for every 20,000 of the
population. A doctor might have as many as 3,000 home visits in a year
and yet this was supposedly on a part-time basis! Nevertheless, during
the second half of the 19th century the problems of ill-health and
disease were being confronted in a serious manner by an assortment of
means, Tuberculosis still remained one the most important causes of
death, but infectious diseases no longer posed the threat they had
earlier in the century. Typhus, scarlet 'fever and smallpox had all
been nearly eradicated by 1901. However, it was obvious that, by 1900,
despite these improvements most Scots were receiving a standard of
health care which was, at best, uneven in quality and, at worse,
non-existent.

3. ILL-HEALTH 1900-1940

3.1 LEGISLATION FOR HEALTH

The first half of the 20th century witnessed
major improvements in access to, and standards within, the system of
public health provision. Just prior to the First World War important
legislation was passed in the form of the Education Act of 1908
providing for compulsory medical inspection of school children. Local
authorities were empowered to provide food and even clothes for those
children who were classed as either poor or needy. Although
authorities in rural areas opposed the scheme it was generally adopted
in the cities.

The health of adult male workers was also
addressed in the National Insurance Acts of 1911-12. Workers in trades
such as shipbuilding and construction earning less than £160 per annum
were included in the scheme, For fourpence a week they were allowed
access to a doctor and appropriate treatment, although consultant and
hospital services were not covered. Even so, the dependants of those
paying into the scheme were not entitled to treatment. The government
had reasoned that a family's poverty was more the result of the chief
breadwinner being sick than his wife or children. Therefore, the
priority was to get him back to work rather than restore a sick child
to health. This was one the most glaring anomalies in the provision of
health care in the decades before the introduction of the National
Health Service. The fact that the National Insurance Scheme did not
cover dependants forced the local authorities to fill the gap.

By 1919 maternity and child welfare schemes were
in place in areas comprising 550/0 of the population of Scotland. Ten
years later this had increased to 940,10, and by 1935 the scheme was
operating in all areas of Scotland. Those Scots living in remote parts
of the Highlands and Islands also saw their access to medical care
improve. These parishes were generally too small and poor to support a
rate- funded medical service and the State was forced to intervene.
The Highlands and Islands Medical Service was established in 1913 by a
grant of £42,000 from the government. The intention was to induce
doctors to settle and practice in these out of the way places, In
time, the scheme became a model for other countries with scattered
populations.

The actions of the government at both the local
and national level in providing health care made the idea of a
national health service fashionable. The size of the public sector was
in any case increasing during the inter-War years. The combined bed
space in local authority and Poor Law hospitals in 1924 was 15,625
beds compared to 8,539 in the private or voluntary sector. The Local
Government Act of 1929 streamlined the number of parishes and
reorganised them into large burghs (population over 20,000) and county
councils (population under 20,000). This reduced the number of
authorities responsible for health care provision and, at the same
time, spread the cost of provision. The 1929 Act also did away with
Poor Law infirmaries by turning them into general hospitals and
encouraged better co-operation between the public and private
hospitals,

Finally, a government commission in 1935
recommended the creation of a National Health Service. It was opposed
by the medical profession, who saw in it the creation of a state
medical service. It was also opposed by the Conservative government.
The plans were shelved, although the experience of the Second World
War made the establishment of a national system a foregone conclusion.

3.2 A HEALTHY NATION?

Much had been achieved by the outbreak of war in
1939. More beds were available in hospitals; more people had access to
medical care; the system had been made more efficient, However, much
remained to be done. Bed space in hospitals for pregnant women and
sick children was still in short supply. The infant mortality rate was
still high, in spite of a fall by a third in the period 190121,
because it had increased during the depression years of the 1920s and
30s. From 1920 onwards and through the 1930s the infant mortality rate
was on average 17-18% higher in Scotland than in England and Wales.
Diphtheria was rife with 15,059 cases reported among children as late
as 1940. John Boyd Orr's "Food, Health and Income" (1935) had shown
that the Scottish diet was insufficient to maintain health. The
continued existence of squalid housing in urban areas of Scotland and
the overcrowding it promoted still had to be addressed, Of Glasgow
children evacuated during the War 31% were found to be infested with
fleas and lice, and scabies were common. The problems highlighted
during the War were addressed and the health and diet of the
population improved. Most of the major anomalies in terms of access to
health care also disappeared.

Due to higher War-time nutritional standards and
easier access to medical treatment, the infant mortality rate fell
during the Second World War to a fifth of the 1901 level, The
post-1945 welfare state improved the social fabric of urban areas
beyond recognition, particularly in the area of housing. As a result
health indicators showed a vast improvement, with the most sensitive
of all - infant mortality - falling by 89%, or from 70.4 deaths per
1,000 births to 7.5 deaths per 1,000 births between 1911 and 1958. In
Aberdeen in 1911 there were 949 deaths among children under 5; 40
years later 98 children died each year in this age group. The infant
mortality rate was reduced from 139 per 1,000 births to 27 over this
period. This was a remarkable achievement by any standards. However,
there was little room for complacency. The west central region of
Scotland in the early 1950s still had the highest child death rate of
any region in the UK. Although there remained discrepancies in terms
of life expectancy between social classes, the battle against the
diseases of poverty had been virtually won by 1950; the battle against
the diseases of affluence were about to begin.

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